ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB035

Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease

This policy governs reimbursement for laboratory tests and diagnostic algorithm–based testing used for the diagnosis and monitoring of inflammatory bowel disease for Blue Cross Blue Shield of New Mexico members and applies to providers submitting claims to the Plan.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyLaboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Policy CodePolicy CPCPLAB035

Change TypeAdded codeminor reimbursement examples and references updated

Effective DateAug 1, 2025

Next Review Date

Key ActionSubmit accurate documentation and bill using code 0598U when appropriate after its effective date.

SourceLink

POLICY UPDATE CHANGES

Added code 0598U effective 10/01/2025.

Reimbursement information revised to include ibs-smart™ as example in #2.

Document updated with literature review on multiple review dates (10/30/2024, 02/01/2024, 11/01/2023).

>10listed as not reimbursable

3algorithm-based tests not reimbursable

13example codes listed

1new code added

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Coverage criteria for IBD laboratory testing

Reimbursement/coverage notes

Background and policy history relevant to reimbursement of IBD-related testing:

Diagnostic algorithm–based testing is not reimbursable for diagnosis or monitoring of IBD (examples cited by the policy include ibs-smart™ and Prometheus® testing).

Policy update history: the document records multiple updates (11/01/2022 initial issuance; revisions with literature reviews on 11/01/2023, 02/01/2024, 10/30/2024) and an Effective Date of 08/01/2025. A coding change was made to add CPT code 0598U effective 10/01/2025.

References and examples cited in the policy include clinical reviews (UpToDate entries), peer-reviewed literature (e.g., Plevy et al. 2013), and Prometheus product pages for IBD sgi/Monitr Crohn's. These sources were used to inform the reimbursement determinations and examples listed in the policy's reimbursement information section.

Procedure and billing codes

Example procedure codesmixed

82397
83516
83520
86021
86036
86037
86255
86671
88346
88350

1–10 of 13

1/2

Recently added codeCPT

0598U

New code added to policy effective 10/01/2025 (per policy history)

Documentation, billing, and provider responsibilities

Documentation Required

Documentation and claim review

Providers are responsible for submission of accurate documentation of services performed and are expected to submit claims using valid code combinations from HIPAA-approved code sets. Claims are subject to code edit protocols and review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic; upon request, providers are urged to submit any additional documentation.

Submit claims using valid HIPAA-approved code combinations and industry-standard coding guidelines (CPT, HCPCS, ICD-10, NDC, DRG, CCI, etc.).
Be prepared to provide additional supporting documentation upon request for claim review and code edits.

Billing Rule

Coding update — addition of code 0598U (10/01/2025)

Definitions and referenced assays

Plan criteria

ScopeApplies to Plan lab management reimbursement criteria for laboratory testing used in the diagnosis and monitoring of inflammatory bowel disease (IBD).

ApplicabilityNot all requirements apply to each product; providers should review Plan documents for eligibility and coverage determinations.

Coverage stanceCertain serologic markers and diagnostic algorithm–based tests for diagnosis or monitoring of IBD are not reimbursable by the Plan.

Provider responsibilityProviders are urged to review Plan documents and submit accurate documentation of services rendered for claims review.

Policy identifierPolicy Number CPCPLAB035 — effective 2025-08-01 (version noted in policy history).

Prometheus IBD sgi / related assays

DefinitionCommercial serologic, genetic, and inflammatory marker panels referenced in the literature and Prometheus product materials (e.g., Prometheus IBD sgi).

Example products citedPrometheus IBD sgi (Prometheus IBD sgi Diagnostic) and Monitr Crohn's (Prometheus Monitr Crohn's) as referenced in Prometheus product pages and literature summaries.

Supporting literatureMultiple peer‑reviewed guidelines and studies cited (e.g., British Society of Gastroenterology 2019; ACG 2018; Plevy et al. 2013; genetic IBD studies).

Policy implicationDiagnostic algorithm–based testing such as Prometheus assays are referenced in the policy and are not reimbursable for diagnosis or monitoring of IBD per exclusion statements.